Management of Cement Effect Hypotension After Arthroplasty

Understanding Bone Cement Implantation Syndrome

The management of bone cement implantation syndrome (BCIS) hypotension requires immediate vasopressor administration, fluid resuscitation, and supportive care to maintain systolic blood pressure within 20% of pre-induction values 1
Bone cement implantation syndrome (BCIS) is characterized by hypotension, hypoxia, and potential cardiovascular collapse that occurs during cemented arthroplasty procedures, with a Grade 1 severity classification of arterial saturation <94% or >20% fall in systolic blood pressure (~20% incidence) 2
Bone cement implantation syndrome (BCIS) has a Grade 2 severity classification of arterial saturation <88% or hypotension >40% fall in systolic blood pressure or loss of consciousness (~3% incidence) 3
Bone cement implantation syndrome (BCIS) has a Grade 3 severity classification of cardiovascular collapse requiring cardiopulmonary resuscitation (~1% incidence) 4

Increasing age is a risk factor for severe cardiovascular events during cemented arthroplasty 4
Male sex is a risk factor for severe cardiovascular events during cemented arthroplasty 4
Significant cardiopulmonary disease is a risk factor for severe cardiovascular events during cemented arthroplasty 4
Use of diuretic medication is a risk factor for severe cardiovascular events during cemented arthroplasty 4

Administer vasopressors promptly, such as metaraminol or adrenaline (epinephrine), in case of cardiovascular collapse 4
Provide fluid resuscitation to ensure adequate intravascular volume 5
Target systolic blood pressure within 20% of pre-induction values 1
Increase FiO2 to maintain adequate oxygenation 4
Monitor arterial oxygen saturation continuously 1
Watch for sudden drops in end-tidal CO2 during general anesthesia, which may indicate right heart failure or catastrophic reduction in cardiac output 1

Ensure adequate hydration before induction and during anesthesia 4
Use thorough femoral canal preparation with pressurized lavage system to clean endosteal bone of fat and marrow contents 2
Employ distal suction catheter with intramedullary plug 2
Apply cement in retrograde fashion using a cement gun 5
Avoid vigorous cement pressurization in high-risk patients 5

Establish clear communication between surgeon and anesthetist before cement application 5
Surgeon should verbally announce intent to prepare femoral canal and apply cement 1
Anesthetist should confirm awareness of cement application 5

Cemented prostheses provide benefits including increased pain-free mobility and reduced reoperation rates 4

Failure to anticipate BCIS - Always be prepared for cardiovascular collapse in cemented arthroplasty 1
Delayed recognition - Early warning signs include drops in systolic pressure 1
Inadequate preparation - Have vasopressors drawn up and ready before cement application 1
Poor communication - Ensure the surgical team maintains clear communication about cement application timing 5